Virtual Surgical Planning Optimizes Mandibular Reconstruction With Free Fibula Flap
Tomer Avraham, MD, Peter Franco, DMD, Stelios Wilson, BA, Daniel Ceradini, MD, Lawrence Brecht, DDS, David Hirsch, DMD, MD, Jamie Levine, MD.
NYU Langone Medical Center, New York, NY, USA.
The free fibula osteocutaneous flap has become the gold standard for reconstruction of complex mandibular defects. Flap contouring and inset remain imprecise, operator dependent, and tie consuming. At our institution we have attempted to make this process more uniform and reproducible through the use of virtual planning and pre-fabricated cutting jigs. The purpose of this study was to review our series free fibula mandibular reconstructions using these adjunctive technologies.
All patients underwent preoperative CT scanning of the face and bilateral lower extremities. These images were then transmitted to an outside vendor. In consultation with the ablative, orthodontic, and reconstructive teams, a surgical plan was devised, cutting jigs for both creation of the mandibular defect and for fibular osteotomies were fabricated, and a streolithic model that allows for precise reconstruction plate bending was created. The rest of the surgical procedure was performed in standard fashion. Following IRB approval, all cases between 2009 and 2012 were identified and retrospectively reviewed. A series of cases performed prior to virtual planning was reviewed for comparison purposes.
Fifty-four reconstructions were performed in 52 patients. Patients were evenly divided between a private, university affiliated medical center and a large county hospital. The most common indications were malignancy (43%), ameloblastoma (26%), osteonecrosis/osteomyelitis (23%), and congenital defects (7%). Thirty percent of patients had irradiation of the recipient site and 38% had previous surgery in said site. A skin paddle was utilized in 85% of cases, and additional osteotomies to create a “double barrel segment” were performed 25% of the time. Sixty-three percent of patients received dental implants into the fibula flap, with 47% achieving functional dentition with dentures. Twenty five percent of patients had immediate dental implant placement, and 9% had immediate dental restoration. Postoperative imaging demonstrated excellent precision and accuracy of flap positioning. Comparison with cases performed prior to utilization of virtual planning demonstrated increased complexity
Pre-operative virtual planning along with use of prefabricated cutting jigs allows for precise contouring and positioning of microvascular fibular free flaps in mandibular reconstruction. Utilizing this technique we have achieved unprecedented rates of dental rehabilitation while reducing operative times. We believe that virtual planning technologies are an emerging gold standard in mandible reconstruction.
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